As you have learned in previous modules, public health measures like physical distancing are necessary to reduce disease transmission. Because the efficacy of these measures depends on high rates of compliance in the general population, COVID-19 can be seen as a behavior-related illness. We must equip ourselves with the tools to best ensure adherence to recommended practices.

Prochaska’s Stages of Change Model

This is an appropriate time to review the six stages of change (Levinson et al., Ann Intern Med 2001). The most effective approach to addressing a change in behavior should take into account the person’s willingness to change, motivating factors towards change, and barriers standing in the way. Although it is not clear whether identifying a person’s “stage” actually helps them change, this framework is important as a roadmap for the process of behavior change, and it aids in discussing individuals engaged in the process of change.

Thought Question:

• With this framework in mind, how would you start a conversation with Brian about physical distancing? How would you start a conversation with Diane about physical distancing?

Motivational Interviewing

This section will provide a refresher course on the principles of motivational interviewing. When engaging people in conversations about behavior changes, the four processes central to the approach are as follows:

Engaging the person in a high quality, mutually satisfying relationship by:

• Expressing appreciation of the person’s main concern, even if they disagree with you. Acknowledge their efforts to change and willingness to engage in discussion.

• Building affiliation by partnering with the person. Collaborate on defining goals and agreeing on strategies, try to face the problem from the same mutual goals (in this case, an example could be reducing spread of disease to loved ones who are at high risk of critical illness)

• Minimizing status differentials: people often assume we have more knowledge and authority than we ourselves think we have. Acknowledge that this person is the expert on their life. Convey information in a straightforward fashion and listen actively.

• Choosing a role that you feel is appropriate for the situation: cheerleader, coach, teacher, monitor, disciplinarian, friend, confessor, etc.

• Emphasizing autonomy, above all: People are much more likely to change if they feel they have the power to choose whether and how to proceed. Emphasize that any next steps are completely up to them. Affirm their strengths and self-efficacy. Point them towards helpful resources that they can consume on their own time.

Focusing on one problem behavior can help improve chances of successfully changing that behavior (as opposed to addressing a broad swath of potential behavior changes at once). This is where the “Ask-Tell-Ask” framework comes into play–when informing people about risks and benefits of various behaviors (see figure below). Help them identify what matters most to them and which behaviors they want to change.

Evoking “change talk” in which patients express their Desires, Abilities, Reasons, Needs, and Commitment to change (DARN-C). This can be done by:

• Summarizing/Reflecting as a part of active listening. You don’t have to use the person’s exact words, as the purpose is to show the patient you are listening and perhaps accentuate their unconsciously uttered change talk.

• “On a Scale from 1 to 10, how likely are you to change X?” Then ask, “Why not a lower number?” This will get them to express motivations for change.

• Ask-tell-ask can also play a role here. Ask the person what they understand about the risks of their behavior. Tell the patient how that relates to what you know. Then ask how this new information might apply to their situation.

Planning next steps that are Specific, Measurable, Achievable, Relevant, and Time-bound (SMART). Remember, this person has the autonomy to execute the plan. All your efforts to this point to reinforce that should enable them to feel motivated to execute it!

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